Fluids and shock Flashcards by Jenny P

Major physiologic determinants of tissue perfusion are:

BP, Cardiac output

How well did you know this?

Not at all

Perfectly

main sign of pre-shock/ compensated shock

tachycardia

How well did you know this?

Not at all

Perfectly

symptoms of shock

Signs and symptoms of end-organ dysfunction
Symptomatic tachycardia, dyspnea, hypotension, cool clammy skin
Metabolic acidosis, oliguria, renal dysfunction

How well did you know this?

Not at all

Perfectly

what type of shock?
Intravascular fluid loss due to:
Hemorrhagic cause
Nonhemorrhagic cause
Third spacing

hypovolemic

How well did you know this?

Not at all

Perfectly

hypovolemic shock effect on cardiac output

decrease in preload (volume in LV at end of diastole)

How well did you know this?

Not at all

Perfectly

fluid options for Nonhemorrhagic hypovolemic shock

1st line is crystalloids (NS, LR), 2nd line is colloids

How well did you know this?

Not at all

Perfectly

class: recombinant factor 7a (novoseven), tranexamic acid

hemostatic agents

How well did you know this?

Not at all

Perfectly

managment for internal bleeding

hemostatic agents, blood

How well did you know this?

Not at all

Perfectly

how to reverse warfarin

4Factor PCC (prothrombin complex concentrate)/KCentra + vitamin K

How well did you know this?

Not at all

Perfectly

how to reverse dabigatran

Idarucizumab/Praxbind or activated PCC

How well did you know this?

Not at all

Perfectly

how to reverse Xarelto, Eliquis

Andexanet alfa or 4F PCC/KCentra

How well did you know this?

Not at all

Perfectly

criteria for septic shock dx

Infection: Invasion of normally sterile tissue by organisms OR Bacteremia.
Organ dysfunction
SOFA (Sequential (sepsis-related) Organ Failure Assessment score
Score ≥ 2
qSOFA can identify patients at risk for sepsis
Score ≥ 2

Patients who require vasopressors despite adequate fluid resuscitation maintain MAP ≥ 65 mmHg
+
Lactate ≥ 2 mmol/L

How well did you know this?

Not at all

Perfectly

septic shock is a type of ____ shock

distributive

How well did you know this?

Not at all

Perfectly

major factor of distributive shock

massive vasodilation

How well did you know this?

Not at all

Perfectly

3 keys points for mgmt of sepsis

Management requires these 3-things:
Early recognition and intervention (including administration of IV fluids (NS or LR) and vasopressors as needed)
Early administration of broad spectrum antibiotics (w/in 1 hr of arrival)
Source control

How well did you know this?

Not at all

Perfectly

rate/amount of fluid restoration for sepsis

30mL/kg total bolus
Given in 500-1000mL bolus
Reassessment performed following each bolus

How well did you know this?

Not at all

Perfectly

indication for vasopressors in sepsis

Recommended in patient with MAP < 60 – 65 mmHg after failed fluid resuscitation. Used when fluid resuscitation is inadequate to maintain blood pressure and prevent organ dysfunction in shock

How well did you know this?

Not at all

Perfectly

central or peripheral line for vasopressors?

central

How well did you know this?

Not at all

Perfectly

1st line vasopressor in septic shock

norepinephrine

How well did you know this?

Not at all

Perfectly

add ___ to NE if persistent hypotension in septic shock

epi

How well did you know this?

Not at all

Perfectly

1st line for shock caused by HF or resulted in HF

dobutamine (but Rarely used in septic shock – only when combined with multiple other vasopressors)

How well did you know this?

Not at all

Perfectly

indication for corticosteroids in shock

Hemodynamic instability despite fluid and vasopressor therapy
IV hydrocortisone: 200 mg/day (50 mg q6h)
Wean from steroids when vasopressor therapy no longer required

How well did you know this?

Not at all

Perfectly

stress ulcer prophylaxis in shock

Drugs that increase gastric pH
Famotidine (Pepcid®) or ranitidine (Zantac®): histamine receptor antagonist
Lansoprazole (Prevacid®) or pantoprazole (Protonix®): proton pump inhibitors

How well did you know this?

Not at all

Perfectly

pts at risk for stress ulcers

Mechanical ventilation (> 48 hours)
Coagulopathic
Hypotensive

How well did you know this?

Not at all

Perfectly

predominant ion in intracellular fluid

plasma w/o clotting factors

serum

predominant ion in interstitial fluid

75% of oncotic pressure is from ____

albumin

brain structure regulating thirst

hypothalamus

should intake ___L of water, pee out ___L

2, 1.5

BUN/Cr ratio in prerenal azotemia / dehydration

>20:1 >20:1

HR and BP in dehydration

rapid HR, low BP

Aqueous solutions of mineral salts or other water soluble molecules * Increases intravascular volume and intracellular volume * Low tendency to stay in intravascular space

crystalloids

isotonic crystalloid; contains Na, Cl, K, Ca, lactate; prevents hyperchloremia acidosis

lactated ringers

NS overload can cause

overload can cause high Na, low K, metabolic acidosis, high Cl

3 contraindications for half normal saline

burns, trauma, cirrhosis

indications for half normal saline

hypernatremia, DKA

indications for Electrolyte-Free Water o D5w: dextrose 5% In water, D10w: dextrose 10% in water

hypoglycemia, critically elevated serum osmolarity

contras for Electrolyte-Free Water o D5w: dextrose 5% In water, D10w: dextrose 10% in water

edema, blood loss, hypovolemia

3% saline (or higher): causes volume expansion where?

larger volume expansion in intravascular space

severe hypovolemia / large quantity of fluid needed. use NS or LR?

LR (to prevent hypercholremic acidosis, AKI)

High concentration solutes and protein designed to keep fluids in intravascular space à “plasma expander” * Large molecules/proteins suspended in solution * Don’t diffuse out of blood stream into interstitial or intracellular space * Draws fluid into bloodstream by oncotic pressure à increases oncotic pressure

colloids

class: Fresh frozen plasma or albumin (natural) o Hespan or Dextran (synthetic)

colloids

pt w/ blood loss--what to give them?

blood

what fluid can reverese a coagulopathy (pre-procedural)?

fresh frozen plasma

quantity of fluid replacement for 68kg adult

For adults: Your patient weighs 68 kg --First take 40 ml/hr --Now add 68 ml/hr (this is the 1 ml/hr per kg of the patient’s weight ) Maintenance IV fluid rate is 40+68=108 ml/hr

quantity of fluid replacement for 25kg kid

Your patient weighs 25 kg (55 lbs): -First 10 kg allow 4ml/kg/hr= 40 ml/hour -Second 10 kg allow 2/mg/kg/hr=20 ml/hr -Everything over gets 1 ml/kg/hr (in this case 5 more kg to make a total of 25 kg) SO…5 ml/hr 40 +20+5= 65ml/hr of chosen IV fluid for maintenance rate.

bolus rate for adults

1-2L at a time

bolus rate for CHF, ESRD

250-500cc, reassess every 2-5min

bolus rate for elderly, kids

also elderly, kids (bolus slowly over 30min-1hr, 10-20cc/kg). don't give too much too fast to kids

what fluid to give burn pts

when to refer burn pt

>10% of BSA burned

when to give sodium bicarb in CKD metabolic acidosis

KDIGO suggests oral replacement when HCO3 concentrations are <22mEq

caution for sodium bicarb

Caution in patients who should maintain a low sodium diet

when to give bolus K+

never

antidote for KCl

hyaluronidase antidote

if giving pt PO KCl, also give ___

meal + full glass of water

caution for KCl

renal failure/insufficiency d/t risk of hyperkalemia

10 mEq of Kcl will increase serum K by ___

0.1

acute hyperkalemia management:

insulin, dextrose, albuterol. if also have EKG changes, give Ca gluconate

Gastrointestinal Cation Exchangers for Hyperkalemia -- ok for renal impairment?

yes

preferred Gastrointestinal Cation Exchangers for Hyperkalemia

Lokelma (zirconium cyclosilicate) § Newer, preferred, works quickly (~1 hr) § May be used for chronic hyperkalemia of CKD/ESRD

contra for Gastrointestinal Cation Exchangers for Hyperkalemia

AVOID use in anyone w/ ileus, severe constipation, bowel obstruction or gastric motility disorders à risk of intestinal necrosis!

indicatin for Potassium Bicarbonate

hypokalemia in pt w/ metabolic acidosis (Ex: diarrhea)

loop vs thiazide diuretic for CKD?

loop, esp if GFR<60